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<br />OMS No. 3067-0027
<br />3. DECLARATION NO.
<br />FEMA {)(.(. 0
<br />4. INSPECTION O^TE
<br />
<br />FEOERAL EMERGENCY MANAGEMENT AGENCY
<br />DAMAGE SURVEY REPORT
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />1, TO lilt REGION
<br />
<br />8
<br />
<br />
<br />FEDERAL EMERGENCY MANAGE!\I1ENT AGENCY
<br />
<br />5. WORK ACCOMPLISHED BY
<br />
<br />f 9
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<br />2. APPLICANT (St3t;Agency~ County--:City: etc.J- ---- ; PA-N~---'-- --- h___
<br />~u _.. _H..Q H....i3L Ct.)_-",-",,-t.)J._ ,___p '.. . D'Zl-:l1JJIIlflL
<br />7. WOHK CATEGORY ("X" Applicable Box) / ' DSR NO. 6.
<br />o EMERGENCY 0 A [J B 24 :J 08
<br />OJ 0 PERMANENT ti'lc [J DOE [J FOG C H D I
<br />----
<br />8. DAr-.1AGED F~CILlTIES (Location, identification and description) .
<br />Co ;<,J, S / fila" A,o (3:,IAN (0 ('..,.,,,,4y L, Ne 755 n. N
<br />
<br />6. /v",l'-ov~ 5 vR ff'r~J (2"110;( 2' wd~_._.----.-l_~ YES __!ji(N~_
<br />
<br />Arof) /1<':/lJ.~/ly 10.51 At f;ve /'.OfAlo,.;;;,
<br />
<br />o CONTRACT
<br />f5i(.FORCE ACCOUNT
<br />
<br />PERCENTAGE' OF WORK
<br />COMPLETED TO DATE
<br />m
<br />
<br />%
<br />
<br />SA. FACILITY IN OR AFFECTS
<br />FLOOD PLAIN OR WET LANDS
<br />
<br />DESCRIPTION OF DAMAGt: / f
<br />~ 1'-1 bl'JN j( M<"""
<br />
<br />011.">",5;0,..,, ON /l1//Jej,.J ::,l,.~f
<br />
<br />10. SCOPE Of PROPOSED WORK
<br />J(t'I'/;lCP t',... b/lr'kMl'Nf; t<e:!!/vel J jJ/lve Af Abo"" 5-/,.05
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<br />/"1( /If/;l(/,pJ ~hul-. A ~o/,..cL;rA I ev~/..."'!-i>AJ Mltybe
<br />Nl"f<"5SI'Ir<y /1",0 ,.,5 ~,.(c,...,...,t'",Jt'J 10 jple,,,,,,,.,,,,. feI'5,b.l.ly,
<br />
<br />QUANTIT-~~--'--UNiT-'
<br />1.1
<br />
<br />11. ESTIMATED COST OF PROPOSED WORK
<br />-- ----------.- -----.----, ---~"----- -------. ------
<br />MATERIAL AND/OR DESCRIPTION
<br />lei
<br />
<br />
<br />
<br />NAP (1101 k/v...:",,,,,, />A..",...,
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<br />3/)1" r ('1"",[,,(( ... "A,,("
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<br />-..)
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<br />_---+-~o s 4/1"3 o~Ue...~
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<br />-. --t---=T='~--=-=- ..-~-____~____,____.___.__
<br />--. _L_. r-..--~.---.-L-u.
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<br />
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<br />
<br />
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<br />12. EXISTING INSURANCE (TvPO)
<br />
<br />--~+----
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<br />
<br />W TOTAL"S L.j Y 729______
<br />E'LiCIBLE ITI ATTACHMENTS
<br />~YEsl~ NO
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<br />ATTACHMENTS
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<br />'ATTACHMENTS
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